Reflexivity: The Creation of Liminal Spaces--Researchers, Participants, and Research Encounters

The Listening Guide: Illustrating an underused voice-centred methodology to foreground underrepresented research populations

AIM

To highlight the value of utilizing the Listening Guide methodology for nursing research and provide an exemplar applying this methodology to explore a novel concept in an underrepresented group-inner strength in persons newly diagnosed with mild cognitive impairment along with their care partners.

DESIGN

Methodology discussion paper.

METHODS

The exemplar study used the Listening Guide methods for data elicitation and analysis. Methods included adaptations for the study population and novice qualitative researchers.

RESULTS

The Listening Guide methodology with adaptations enabled the research team to centre the voices of persons living with mild cognitive impairment, highlight an abstract phenomenon and attend to the influences of the sociopolitical context. Further, this methodology helped address common challenges emerging qualitative researchers encounter, including understanding methods of application, engaging reflexively and immersing in the data.

CONCLUSION

The Listening Guide is a voice-centred qualitative methodology that is well suited to foreground the experiences of groups underrepresented in research and explore emerging phenomena.

IMPLICATIONS FOR NURSING

Nurses are central to striving for health equity. The Listening Guide methodology offers a valuable and accessible research tool to understand the experiences and needs of underrepresented groups and shape healthcare in response.

IMPACT

The Listening Guide methodology can be broadly applied to research with persons with mild cognitive impairment, and other underrepresented groups, to explore other phenomena beyond inner strength and move the science forward in representing the perspectives of groups underrepresented by research.

PATIENT OR PUBLIC CONTRIBUTION

Persons living with cognitive impairment and their care partners participated in study conceptualization, interview guide development, methods development and dissemination plans.

Israeli Single Gay Fathers' Choice of Lone Parenthood via Surrogacy: A Qualitative Study

This article focuses on Israeli single gay fathers' reproductive choices. Thematic analysis of 13 in-depth semi-structured interviews with Israeli single gay fathers yielded two themes related to their reproductive choice. The first theme pertains to their decision to become single fathers. Three dimensions were prominent in the participants' decision to pursue lone parenthood: the choice to fulfill parenthood as gay men; the choice to separate parenthood from couplehood; and the view of single parenthood as empowerment. The second theme pertained to the fathers' decision to use surrogacy, which was influenced by three key factors: the desire to parent a biological child, the desire for exclusive fatherhood, and the perceived advantages of surrogacy for single fathers. The findings indicate that the fathers narrated their reproductive experiences in terms of choice and autonomy, while negotiating with dominant concepts of parenthood as a two-parent, heteronormative and biogenetic phenomenon. These men referred to the challenge they posed to some of these concepts and the social barriers they encountered as factors that facilitated their coping skills in lone parenthood, thereby enhancing their agency. These findings highlight the contextual, multidimensional and relational nature of the reproductive choices of men from minority groups like single gay fathers.

Sexual grooming processes carried out by offending rabbis toward religious men and their families

BACKGROUND

Research regarding sexual grooming in cases of sexual abuse by religious authorities (SARA) is limited, despite the assumption that many SARA cases go unreported. To the best of our knowledge there is no research regarding sexual grooming committed by rabbis who sexually abused Israeli Jewish religious men.

OBJECTIVE

The present study examined how Israeli religious SARA victims and their family members experienced sexual grooming carried out by offending rabbis.

METHODS

Based on a constructivist-phenomenological paradigm, semi-structured in-depth interviews were conducted with 16 formerly and/or currently still religious men who had been sexually abused by rabbis in their adolescence, and 14 of their family members.

RESULTS

In comparison to the Sexual Grooming Model (SGM), findings showcased that unlike other kinds of sex offenders, offending rabbis incorporated religious elements throughout the grooming process. Additionally, offending rabbis used different grooming tactics than did Catholic priests (e.g., offering joint religious studies with victims' family members; using religion to justify sexual discourse and contact).

CONCLUSIONS

The findings expand the SGM, enable a more complex understanding of the grooming processes in SARA, and emphasize the importance of further research focused on increasing the ability to use the SGM for detecting and preventing grooming behaviors.

Torture survivors' experiences of receiving surgical treatment indicating re- traumatization

Due to the invasive nature of surgical procedures and the involvement of medical personnel, torture survivors may experience re-traumatization during surgical treatment. This study aimed to explore torture survivors' experiences of re-traumatization during surgical treatment as well as the process by which trauma-related emotions and responses are evoked during surgical treatment for torture survivors. Eight men, aged 45 to 72, from four different countries, who have lived in Norway for 6-40 years, were recruited. We assessed torture and surgical care experiences through in-depth interviews, and the data were analyzed using thematic analysis, resulting in five themes: (1) Interactions with healthcare providers, (2) Reactions during treatment, (3) Triggers causing re-experiences, (4) Avoidance, and (5) Suggestions to healthcare providers. In this study, survivors reported challenges receiving surgical treatment, indicating re-traumatization and difficulty returning to daily life following treatment. Participants reported little collaboration in care-related decision-making processes, lack of recognition of torture by healthcare providers involved in surgical care and experiencing healthcare professionals' attitudes as a source of perplexity, frustration, and despair. Exacerbation of torture memories throughout treatment and re-experiencing of trauma symptoms aggravated these difficulties. Our findings suggest that surgical treatment can remind torture survivors of the traumatic aspects of torture, eliciting strong reactions and feelings like those experienced during torture.

The religious implications of being sexually abused by a rabbi: Qualitative research among Israeli religious men

BACKGROUND

Clergy perpetrated sexual abuse (CPSA) is a widespread phenomenon, with many consequences for the victims. To the best of our knowledge, no research has focused on the religious consequences for Israeli Jewish religious men who were sexually abused by rabbis in their adolescence or emerging adulthood.

OBJECTIVE

To describe the implications of CPSA for the religious faith, practice, and attitude towards rabbis among sexually abused Israeli religious men.

METHODS

Based on a constructivist-phenomenological paradigm, semi-structured in-depth interviews were conducted with eight formerly and/or currently still religious men who had been abused by rabbis.

RESULTS

Three main themes regarding religious consequences, emerged from the findings: the impact of CPSA on the religiosity of the victims; the effect of being sexually abused by a rabbi on victims' attitudes toward other rabbis; and the process of finding a new rabbi after the abuse.

CONCLUSIONS

This preliminary study opens a window onto the complex nature of this type of sexual abuse and its religious consequences. The unique findings regarding the range of religious implications are not consistent with previous studies about Christian victims. These findings contribute to the understanding of this distinctive form of abuse, for establishing intervention techniques that will assist the victims and for additional research.

At odds: How intraprofessional conflict and stratification has stalled the Ontario paramedic professionalization project

Historically, self-regulation has provided some professions with power and market control. Currently, however, governments have scrutinized this approach, and priorities have shifted toward other mandates. This study examines the case of paramedics in Ontario, Canada, where self-regulation is still the dominant regulatory model for the healthcare professions but not for paramedics. Instead, paramedics in Ontario are co-regulated by government and physician-directed groups, with paramedics subordinate to both. This paper, which draws on interviews with paramedic industry leaders analyzed through the lens of institutional work, examines perspectives on the relevance of self-regulation to the paramedic professionalization project. Participants had varying views on the importance of self-regulation in obtaining professional status, with some rejecting its role in professionalization and others embracing regulatory reform. Because paramedics disagree on what being a profession means, the collective professionalization project has stalled. This research has implications for understanding the impact of intraprofessional relationships and conflict on professionalization projects.

Opportunities for Poetic Analysis in Qualitative Nursing Research

BACKGROUND

The voices of people living with serious, life-limiting illnesses are often underrepresented in research. Furthermore, a biomedical bias toward treatment and stigma associated with illness prevents healthcare providers from engaging with topics critical for people living with serious illness, such as existential communication and inner strength. Poetry is an established method of analysis and dissemination in qualitative research but is underutilized by nursing researchers.

OBJECTIVES

The purpose of this article is to demonstrate the inherent opportunities in using poetry in nursing research to highlight the voices and issues of people whose experiences are outside the assumed norms of the biomedical paradigm.

METHODS

We apply methods of poetic analysis to qualitative data sets that highlight the voice of people living with serious illness-in naturally occurring palliative care conversations and dyadic interviews of people with dementia and their care partners. Methods of poetic analysis include poetic transcription and voice poems.

RESULTS

Methods of poetic analysis allowed us to engage with the data reflexively to intensify and evoke the deeper meaning of narratives. Poetic analysis served to center the participant's voices by using their own words to demonstrate themes. Poems are a uniquely accessible method of disseminating complex findings, as poems relay layered cognitive and emotional meaning resonant of universal human experiences in a concise and relatable format.

DISCUSSION

Especially in circumstances where participant's voices are underrepresented, poetic analysis enables nurse researchers to challenge normative assumptions and reimagine a difference-centered society. Our findings offer opportunities to incorporate poetry into clinical and research nursing training to better meet the needs of the populations we serve.

"We're talking about black men here, there's a difference"; cultural differences in socialised knowledge of prostate cancer risk: A qualitative research study

PURPOSE

To detail social knowledge of prostate cancer risk amongst cultural groups. Prostate cancer is the most common cancer in men, and black men are at the highest risk. Despite this, black men are the least likely to be diagnosed early with prostate cancer. It is important to understand why this is so that these men can receive early access to effective treatment and support.

METHODS

A constructivist grounded theory methodology was used. Data were collected between December 2015 and October 2017; seventeen men were interviewed, and eighteen men took part in focus groups.

RESULTS

There were differences in the way the men constructed their understanding of risks for prostate cancer. The social construction of prostate cancer risk knowledge was mediated by the way the men were socialised to understand and accept this risk. The Somali and African Caribbean men placed social importance on the healthy body, whereas the white working class men seemed to find social value through the unwell body. This research proposes the theory that social constructions of knowledge mediate the way men perceive and accept their risk for prostate cancer.

CONCLUSION

Understanding socially-derived knowledge of risk may mediate the acceptance of factors relating to prostate cancer. This knowledge may help health providers and third sector organisations produce targeted health-related information. Health practitioners may also benefit from understanding how socially constructed ideas of the body could influence the way men respond to conversations about prostate cancer so that tailored and culturally appropriate support can be offered.

The role of the household in the social inclusion of children with special needs in Uganda - a photovoice study

Background

Social inclusion establishes a basis for the overall wellbeing of children with special needs. Although children’s lives are centred around the household, little is known about the household’s influence on social inclusion. Therefore, the aim is to investigate the household’s role in the social inclusion of children with special needs in Uganda.

Methods

Twelve carers of children with special needs participated in this photovoice study on the outskirts of Kampala, Uganda – including a training workshop, home visits, in-depth individual interviews and focus group discussion.

Results

The social inclusion of children with special needs is highly complex because it has the potential to both benefit and cause harm. The results show that when a disability is socially devalued to a certain degree, carers and their household members have to deal with the ongoing process of stigma management. Depending on the characteristics of the child, carer and household, this can lead to an upward spiral towards visibility or a downward spiral towards concealment – reinforcing social inclusion or stigma, respectively.

Conclusions

Despite the fact that there is disability among Ugandan children it remains a ‘hidden reality’. This research helps to reveal this hidden reality by understanding the role of the household in social inclusion in a stigmatized context.

Various structural factors influenced early antiretroviral therapy initiation amongst HIV infected prisoners: a qualitative exploration in South Ethiopia

Background

Early initiation of antiretroviral therapy (ART) reduces the development of acquired immunodeficiency syndrome (AIDS), non-AIDS related comorbidities and mortality, and prevents transmission. However, the prevalence of delayed ART initiation amongst prisoners in sub-Saharan African countries is high and the contributing factors to this are relatively unknown.

Methods

Qualitative interviewing was employed to understand the prisoners’ lived world with regard to initiating ART and associated barriers and facilitators in the South Ethiopian prison system. We interviewed seven (five male and two female) inmates living with HIV (ILWH) and eleven stakeholders who had a role in human immunodeficiency virus (HIV) care provision for incarcerated people. A phenomenological approach was used to analyse the interview data in which meaning attributed to the lived experiences of the participants was abstracted.

Results

In this study, participants discussed both barriers to, and facilitators of, early ART initiation during incarceration. The barriers included a lack of access to voluntary counselling and testing (VCT) services, poor linkage to care due to insufficient health staff training, uncooperative prison security systems and loss of privacy regarding disclosure of HIV status. Insufficient health staff training and uncooperative prison security systems both contributed to a loss of patient privacy, ultimately resulting in treatment refusal. Although most participants described the importance of peer education and support for enhancing HIV testing and treatment programs amongst prisoners, there had been a decline in such interventions in the correctional facilities. Service providers suggested opportunities that a prison environment offers for identification and treatment of HIV infected individuals and implementation of peer education programs.

Conclusions

Our study identified crucial barriers to and facilitators of early ART initiation amongst prisoners, a key HIV priority population group. Interventions that address the barriers while strengthening the facilitators may enhance a greater utilisation of ART.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11499-w.

An Ecological Model for High-Risk Professional Decision-Making in Mental Health: International Perspectives

Mental health professionals are frequently presented with situations in which they must assess the risk that a client will cause harm to themselves or others. Troublingly, however, predictions of risk are remarkably inaccurate even when made by those who are highly skilled and highly trained. Consequently, many jurisdictions have moved to impose standardized decision-making tools aimed at improving outcomes. Using a decision-making ecology framework, this conceptual paper presents research on professional decision-making in situations of risk, using qualitative, survey, and experimental designs conducted in three countries. Results reveal that while risk assessment tools focus on client factors that contribute to the risk of harm to self or others, the nature of professional decision-making is far more complex. That is, the manner in which professionals interpret and describe features of the client and their situation, is influenced by the worker's own personal and professional experiences, and the organizational and societal context in which they are located. Although part of the rationale of standardized approaches is to reduce complexity, our collective work demonstrates that the power of personal and social processes to shape decision-making often overwhelm the intention to simplify and standardize. Implications for policy and practice are discussed.

Liminal space and the negotiation of care work in extra-care housing

This is a qualitative case study of care work in a liminal space, specifically the case of an extra-care housing residence, which is an innovative housing alternative for elderly people in need of care in Sweden. The study is an exploration of social care workers' perceptions about their workplaces and their understandings of themselves, which are shaped by their embeddedness in architectural space. The extra-care housing residence appeared as a liminal space in which two dominant spaces - home care services and residential care - underpinned the staff's perceptions of an unclear workplace and their identity work.

What do they get out of it? Considering a partnership model in health service research

A research study to evaluate the implementation of a long-term conditions model of care provoked questions regarding the potential impact of the researcher’s role in health service research. Traditional methods of qualitative interviewing require researchers to be a disembodied presence, objective, and free from bias. When health service research is conducted by health professionals, role conflict may occur if the topic is one they have expertise in, and therefore the ability to provide guidance or information. An alternative perspective to the idea of an independent and objective researcher is the notion of a partnership. In this research collaboration, participants utilised the interview process to reflect and explore different perspectives, and the researcher bracketed their own participation in the phenomenon being studied. Reflexivity was utilised by both participants and the interviewer to ensure transparency and thus bridge the gap between subjectivity and objectivity in qualitative health service research interviewing.

Clinical facilitators' experience of near peer learning in Australian undergraduate nursing students: A qualitative study

BACKGROUND

To mitigate escalating costs in clinical supervision of undergraduate nursing students and alleviate clinical facilitators' teaching burden, the near-peer learning model has become popular. Studies on near-peer learning have been on students' views of the model with a paucity of literature on clinical facilitators' experiences.

AIM

To explore clinical facilitator experiences of the near-peer learning model.

DESIGN

A qualitative descriptive design was used with a purposeful sample of clinical facilitators involved in near-peer learning of nursing students.

SETTING

Two teaching hospitals participated. Two medical and two surgical wards were selected from each.

PARTICIPANTS

Eleven clinical facilitators who had experienced using near-peer learning.

METHODS

Focus group and individual interviews were conducted with clinical facilitators using a semi-structured interview guide following ethics approval. Data were analysed using content analysis.

RESULTS

Four themes emerged: 1) Congruent student dyad characteristics 2) Clinical facilitator attributes of confidence in students' knowledge and effective time and conflict management, 3) Availability of suitable skills, and 4) Facilitator support and preparation on the model. These themes appear to promote optimum learning outcomes of the near-peer model including empowering students, junior students gaining practice in foundation skills and senior students gaining competence in leadership, mentoring and nurturing skills. Barriers included incongruent student characteristics resulting in conflict and trust issues, senior student not knowing how to teach, give feedback or teaching inaccurate information; facilitator's lack of confidence in students' knowledge level, inadequate time to manage the student dyad and resolve conflict; inadequate support and preparation from university staff; and unavailability of suitable skills.

CONCLUSION

Successful implementation requires careful selection of student dyads, appropriate clinical environment and support for clinical facilitators. Our findings provide a better understanding of the near-peer model for future implementation.

Unintended consequences: a qualitative study exploring the impact of collecting implementation process data with phone interviews on implementation activities

Background

Qualitative data are crucial for capturing implementation processes, and thus necessary for understanding implementation trial outcomes. Typical methods for capturing such data include observations, focus groups, and interviews. Yet little consideration has been given to how such methods create interactions between researchers and study participants, which may affect participants’ engagement, and thus implementation activities and study outcomes. In the context of a clinical trial, we assessed whether and how ongoing telephone check-ins to collect data about implementation activities impacted the quality of collected data, and participants’ engagement in study activities.

Methods

Researchers conducted regular phone check-ins with clinic staff serving as implementers in an implementation study. Approximately 1 year into this trial, 19 of these study implementers were queried about the impact of these calls on study engagement and implementation activities. The two researchers who collected implementation process data through phone check-ins with the study implementers were also interviewed about their perceptions of the impact of the check-ins.

Results

Study implementers’ assessment of the check-ins’ impact fell into three categories: (1) the check-ins had no effect on implementation activities, (2) the check-ins served as a reminder about study participation (without relating a clear impact on implementation activities), and (3) the check-ins caused changes in implementation activities. The researchers similarly perceived that the phone check-ins served as reminders and encouraged some implementers’ engagement in implementation activities; their ongoing nature also created personal connections with study implementers that may have impacted implementation activities. Among some study implementers, anticipation of the check-in calls also improved their ability to recount implementation activities and positively affected quality of the data collected.

Conclusion

These results illustrate the potential impact of qualitative data collection on implementation activities during implementation science trials. Mitigating such effects may prove challenging, but acknowledging these consequences—or even embracing them, perhaps by designing data collection methods as implementation strategies—could enhance scientific rigor. This work is presented to stimulate debate about the complexities involved in capturing data on implementation processes using common qualitative data collection methods.

Trial registration

ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

Methodological and ethical challenges while conducting qualitative research on spirituality and end of life in a Muslim context: a guide to novice researchers

Abstract Spirituality could be understood as a personal belief, a relation with sacred, divine experience, a sense of purpose and meaning towards life, authenticity and connectedness. It is a continually evolving, highly complex, contextual, subjective, and sensitive construct. A continuous development is seen around understanding about spirituality and spiritual concepts, such as spiritual experiences, spiritual pain and spiritual distress, especially among patients and families at the end of life. The concepts, values, attitudes, and beliefs around spirituality, spiritual needs and expressions vary among different individuals, cultures, and religions. There is a dearth of literature around spirituality, especially among Muslim patients and families at the end of life. The complexities around the concept of spirituality in the literature raise several ethical and methodological concerns for a novice researcher while planning and conducting a study on spirituality during end-of-life care in a hospice setting, especially among a Muslim population. This paper aims to share some of the methodological and ethical challenges that can be faced by qualitative researchers while conducting research around spirituality and end-of-life care in an Islamic/Muslim context. Major challenges include defining the term spirituality, spirituality and culture, communication, power relations, language and translation, recruitment and selection of the participants, emotional distress, and reflexivity and reciprocity. Having an in-depth understanding of these challenges can guide researchers to address these issues adequately in their spirituality research in a Muslim context.

It takes two to tango: carers' reflections on their participation and the participation of people with dementia in the James Lind Alliance process

Background

Worldwide, patient and public involvement (PPI) in health research has grown steadily in recent decades. The James Lind Alliance (JLA) is one approach to PPI that brings patients, carers and clinicians together to identify priorities for future research in a Priority Setting Partnership (PSP). Our study aim was to describe the reflections of informal carers of people with dementia on the possibility of participating in the JLA’s PSP process, for both themselves and the recipients of their care. In addition, we wanted to explore barriers to and facilitators of their participation.

Methods

We conducted four focus groups with 36 carers of people with dementia. Thematic analysis was applied to analyse the data.

Results

An overarching theme emerged from the participants’ reflections: “Creating empowering teams where all voices are heard”. The overarching theme incorporates the participants’ suggestions about the importance of equivalence in power, mutual agreement with and understanding of the goals, adequate support, openness about each partner’s tasks and the bonds needed between the partners to sustain the enterprise, and expectations of positive outcomes. From the overarching theme, two main themes emerged: “Interaction of human factors, the PSP process and the environment” and “The power of position and knowledge”. The overall results indicated that carers are willing to participate in PSP processes and that they thought it important for people with dementia to participate in PSP processes as well, even if some might need extra support to do so. The carers also identified the need for research topics that influence their everyday lives, policy development and healthcare services.

Conclusions

Both carers and the people with dementia for whom they care are able to contribute to the PSP process when given sufficient support. The involvement of these groups is important for setting healthcare research agendas, developing research projects that increase awareness and knowledge about their circumstances and improving health professionals’, researchers’ and policymakers’ understanding of and insight into their unique situations.

Ethnography in health professions education: Slowing down and thinking deeply

CONTEXT

Ethnography has been gaining appreciation in the field of health professions education (HPE) research, yet it remains misunderstood. Our article contributes to this growing literature by describing some of the key tensions with which both aspiring and seasoned ethnographers should productively struggle.

METHODS

We respond to the injunction made by Varpio et al (2017) that HPE researchers should ground their methodological ventures in their historical and philosophical tenets. To do so, we first review core ethnographic texts that provide a background for ethnographic research in HPE, then provide an orienting definition to bind the specificities of ethnographic research. Finally, we review core theoretical and practical considerations for ethnographic research.

RESULTS

Ethnography is a slow and deep approach to knowledge production, and as such it requires careful engagement with theory and deliberate choice of methods. Core theoretical tensions include the ontological, epistemological and axiological dimensions of ethnography, and concerns with quality and rigour. Practical tensions include the scope and remit of ethnography, the importance of observing naturally occurring behaviour and the crafting of rich field notes.

CONCLUSIONS

We encourage ethnographers to pursue scholarship that challenges the status quo. Ethnographers should favour deep encounters with research participants, dig deep into the cultural and structural aspects of HPE and be reflexive about knowledge outputs. At a time in HPE when the pressures to publish are high, using ethnography as a research methodology offers an opportunity to slow down and think deeply.

Bridging the gap between research-based knowledge and clinical practice: a qualitative examination of patients and physiotherapists' views on the Otago exercise Programme

Background

Falls and fall-related injuries exacerbate the health problems of older adults, and they are a public health concern. Despite an abundance of research, the implementation of evidence-based fall prevention programs has been slow and limited, additionally and these programs have not reduced the incidence of falling. Therefore, the primary objective of the present study was to examine patients and physiotherapists’ views on the factors that influence the implementation of the community- and evidence-based Otago Exercise Programme for fall prevention.

Methods

We conducted eight in-depth interviews with physiotherapists and patients, and a focus group interview with 12 physiotherapists and authority figures who represented local hospitals and municipalities. The resultant qualitative data were subjected to thematic analysis.

Results

The analysis yielded two main themes: the researcher’s role and position in the implementation process and the tension between research-based knowledge and clinical practice. The participants believed that research-based knowledge can address the challenges of clinical practice. Further, the patients reported that the fall prevention program made them feel safe and enhanced their ability to cope with daily life. The physiotherapists also observed that research findings do not readily translate into clinical practice. Further, they contended that research-based knowledge is not universal and that it cannot be generalized across different contexts; instead, it must be adapted and translated into a user-friendly language. The findings suggest that the application of research-based knowledge does equate to filling up empty jars and that research-based knowledge does not flow from the expert to the non-expert as water through a tube. Indeed, physiotherapists and patients are not tabula rasa. Additionally, the participants believed that researchers and stakeholders must think critically about who has the power and voice to create a common understanding.

Conclusions

Our findings delineate the means by which the gap between research and practice regarding the Otago fall prevention program can bridged. The program can guide clinical work and provide important information that can be used to improve the quality of other fall prevention programs. However, the research-based knowledge that it confers must be adapted for use in clinical contexts.

Enriching medical trainees' learning through practice: a video reflexive ethnography study protocol

INTRODUCTION

Supporting medical students' and junior doctors' development in busy clinical settings is challenging. As opportunities for developing trainees, for example, traditional bedside teaching, are decreasing, teaching outside of clinical practice is increasing. However, evidence suggests that effective learning through practice arises via an interplay between, first, what experiences are afforded by clinical settings and, second, how trainees engage with these affordances. Many studies investigating clinician learning through practice focus on only one of these two factors. Yet, a well-recognised methodological challenge of enabling learners to articulate how and what they are learning through practice exists. We need, therefore, to understand how this relationship plays out in practice in ways that enrich learning.

METHODS AND ANALYSIS

This protocol describes a video reflexive ethnographic approach to illuminate how learning through practice in hospital settings occurs and can be enriched. The study will be conducted in two phases. In phase I, senior clinicians from emergency medicine, medicine and surgical specialties will be interviewed about how they guide trainees' learning through practice. These forms of guidance, analysed using the framework method, will inform phase II comprising observations of practice in: (1) emergency, (2) medical and (3) surgical departments. Video recorded episodes of clinicians' guiding learning through practice will be shared and appraised in reflexive sessions with each clinical team. Relational interdependent learning theory informs the design and data analyses to elicit and evaluate strategies for guiding learning through practice.

ETHICS AND DISSEMINATION

Ethical approval has been received from both healthcare and university settings. The findings should provide important insights for clinicians about workplace learning practices. Findings will be disseminated across the project phases and to diverse audiences-locally, nationally and internationally. The dissemination strategy will use seminars, grand rounds, conference presentations and academic papers to articulate practical, theoretical and methodological findings.

Nursing students' perceptions towards being taught the fundamentals of care by clinical nurses within a simulated learning environment: A qualitative study

Research in nursing education demonstrates that the fundamentals of care are paid less attention in this field resulting in negative consequences for students' learning outcomes. The aim of this qualitative study was to explore nursing students' perceptions towards being taught the fundamentals of care by clinical nurses within a simulated learning environment. The study has a qualitative explorative design. Data was collected through participant observation and focus group interviews and analysed using qualitative content analysis. The analysis revealed two main categories indicating how the students gained knowledge in the research setting: 'Getting the best of both worlds', and 'Having it in many ways'. The findings are discussed against Vygotsky's theory of cognitive development suggesting that the students were content with being taught the fundamentals of care by clinical nurses within an simulated learning environment.

Dualism, Tension, and Integration: Dialectics as a Theme of Integration in Daily Lives of Israeli Gay Men Who Became Fathers Through Overseas Surrogacy

This article explores the constructed meanings of lived experiences of Israeli gay men who became parents through commercial overseas surrogacy. Based on the analysis of 39 in-depth, semistructured interviews with gay fathers, we show that their parenting experiences are shaped in contradictory ways, allowing them to adopt a reflective position in relation to existing social frameworks. Data from in-depth interviews reveal three major themes. The first refers to the gap between biogenetic and social concepts of parenthood and kinship. The second presents the dialectics between continuity and change that gay parenthood exhibits. The third theme focuses on the impact of these contradictions on gay parents' identities and the construction of autonomy concepts in their lives. By doing so, we highlight the importance of tensions and contradictions in shaping the daily living experiences of gay parents, as well as the importance of dialectics in promoting gay parents' integration within heteronormative society.

Developing nurses' intercultural/intraprofessional communication skills using the EXCELLence in Cultural Experiential Learning and Leadership Social Interaction Maps

AIMS AND OBJECTIVES

To examine how the use of Social Interaction Maps, a tool in the EXCELLence in Cultural Experiential Learning and Leadership Program, can enhance the development of nurses' intercultural/intraprofessional communication skills.

BACKGROUND

Nurses face communication challenges when interacting with others from similar background as well as those from a culturally and linguistically diverse background. We used the EXCELLence in Cultural Experiential Learning and Leadership Program's Social Interaction Maps tool to foster intercultural/intraprofessional communication skills in nurses. Social Interaction Maps describe verbal and nonverbal communication behaviours that model ways of communicating in a culturally appropriate manner. The maps include four stages of an interaction, namely Approach, Bridging, Communicating and Departing using the acronym ABCD.

DESIGN

Qualitative approach was used with a purposeful sample of nurses enrolled in a postgraduate course.

METHODS

Fifteen participants were recruited. The Social Interaction Map tool was taught to participants in a workshop where they engaged in sociocultural communication activities using scenarios. Participants were asked to apply Social Interaction Maps in their workplaces. Six weeks later, participants completed a semistructured open-ended questionnaire and participated in a discussion forum on their experience of using Social Interaction Maps. Data were content-analysed.

RESULTS

Four themes identified in the use of the Social Interaction Maps were (i) enhancing self-awareness of communication skills; (ii) promoting skills in being nonconfrontational during difficult interactions; (iii) highlighting the importance of A (Approach) and B (Bridging) in interaction with others; and (iv) awareness of how others interpret what is said C (Communicating) and discussing to resolve issues before closure D (Departing).

CONCLUSIONS

Application of the EXCELLence in Cultural Experiential Learning and Leadership Social Interaction Mapping tool was shown to be useful in developing intercultural/intraprofessional communication skills in nurses.

RELEVANCE TO CLINICAL PRACTICE

Professional development programmes that incorporate EXCELLence in Cultural Experiential Learning and Leadership Social Interaction Maps can enhance nurses' intercultural/intraprofessional communication competencies when engaging with others from culturally and linguistically diverse backgrounds and improve the way nurses communicate with each other.

Designing programmes of assessment: A participatory approach

Programmatic approaches to assessment provide purposeful and meaningful assessment yet few examples of their development exist. The aim of this study was to describe the development of a programme of assessment using a participatory action research (PAR) approach. Nine work-based assessors together with three academics met on six occasions to explore the current approach to competency-based assessment in the placement component of a dietetics university course, the findings of which were used to design a programme of assessment. Findings revealed disconnect between current assessment approaches and best practice. The PAR methodology fostered a shared vision for the design of a programmatic approach to assessment and strong leadership was essential. Participants experienced a philosophical shift in their views towards assessment, supporting the implementation of a new assessment programme. This paper is the first to describe a PAR approach as a feasible and effective way forward in the design of programmatic assessment. The approach engaged stakeholders to strengthen their abilities as work-based assessors and produced champions for best practice assessment.

Building Power Between Polarities: On the Space-in-Between

In this article, I introduce the concept of the space-in-between. This space-in-between is born of the realization that, between the expression of any two polarities (across dimensions such as emotion, thought, geography, and ideology), there exists a philosophical construct useful for framing thinking about practice, research, and managerial relationships in the health professions. Out of this construct emerge practical considerations useful for structuring the conduct of meaningful interpersonal and intercultural interactions. I describe how the idea of a space-in-between developed out of my medical practice, grew as a result of my experiences in international environments. and has found fulfillment in my ongoing work. I explore the application of a space-in-between in public health, medical anthropology, medical ethics, and global health. I review how, as a result of incorporating this space in their daily work, clinicians, educators, researchers, and managers can grow as leaders by sharing the presence that arises from the space-in-between them and the people in the communities they serve.